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WAL-MART PHARMACY 10-1757
DSH240047 St. Luke's Hospital of Duluth
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Covered Entity Details
Entity Name
St. Luke's Hospital of Duluth
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240047
Entity Address
915 East First Street
Duluth, MN 55805
Medicare Provider Number
240047
Participating Start Date
10/1/2013
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1757
Pharmacy Address
4740 WEST MALL DRIVE
HERMANTOWN, MN 55811
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris H. Johnson, Controller
(218) 249-5486
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/16/2023
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